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Comprehensive orthodontic approach of the excessive gingival smile Mona Ghoussoub. August 12th 2021. Episode 123

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Farooq Ahmed

 

Join me as I summarise Mona Ghoussoub’s lecture looking at the excessive gingival display (EGD).

 

Mona looked at the diagnosis and treatment of EGD, with a focus on aetiology leading to treatment method, effect of age, and input of multidisciplinary care for appropriate cases.

 

Definition Kokich 1999, Machado 2014

  • Negative effects = 4mm + gingival display

 

 

Diagnosis identifying aetilogy

  • Medical history – medication
  • Facial analysis – VME
  • Lip analysis –
    • short lip: lip length 20-22mm
    • hypermobility of elevator muscles
    • Lip line
    • Age increases = greater increase in mandibular incisor show, after 40 years of age, great mandibular incisor show then maxillary incisor show
    • Location, anterior or posterior increase
  • Dental analysis – Short crowns = crown height
    • Maxillary incisor width : height = 80%
    • Centreline Coincident = well intercuspation
  • Periodontal examination
    • Altered passive eruption
      • Pocket without pathology

 

 

 

Treatment approach

 

Early treatment

  • Medical ENT allergology
    • Excessive gingival show age 7-8 years
    • Nasal obstruction causes decrease in lip closing force Sabashi 2011
    • Detect and refer ENT if suspect nasal obstruction
      • Dark eyes
      • Flat cheeks
      • Increase LAFH
    • Orthodontic – prevention
      • Utility arch
        • Intrusion upper anterior teeth
        • 4 brackets and molar bands
        • Retain with 2 layers of Essix + brass wire – for rigidity

Late treatment

  • Orthodontic
    • Alignment
      • 2 occlusal planes in maxilla in 2 div 2, posterior higher, anterior lower
        • Straight wire – reciprocal effects
          • Intrusion of anterior teeth
          • Extrusion of posterior teeth
        • Expansion
          • RME
            • Posterior expansion = gingival position moves upwards
              • When constricted, greater posterior gingival show

 

  • Intrusion
    • Ricketts / Burstone 3 piece intrusion arch
    • Headgear – J hook intrude upper anterior teeth
    • TAD placement for anterior intrusion
      • UR1-UL1 labial
      • Powerchain archwire to TAD
    • TAD for posterior intrusion
      • U5-U6 region buccal
      • Direct retraction U3- TAD
        • Below centre of rotation = posterior intrusion

 

  • MDT
    • Periodontics
      • Gingivectomy – passive over-eruption of dentition
        • Ideal where tooth width:height ratio increased
      • Guided Tissue Regeneration for VME
        • Stable after 1 year
        • 40-60% improvement in excessive gingival growth, with crown lengthening
        • Bony cavity at anterior superior aspect of maxilla
          • Results in the lip raising higher
          • Bone augmented at the level of the Le-fort 1
          • Can be clinically simulated with cotton wool rolls in upper labial sulcus and taking photos
        • Orthognathic surgery
          • Decompensate
            • Maxillary impaction
          • Plastic surgery Pierre 2020
            • Short lip / mild VME = lip repositioning surgery Rubinstein 1973
              • Limit the smile muscle pull by reducing the depth of the upper vestibule– zygomaticus minor, levator Angulo, orbicularis oris, levator labil superior Tawfik 2018
              • Conservative when compared to OGN
              • Technique
                • Split thickness flap – expose connective tissue
                • Advance mucosa and suture at mucogingival junction
              • Limited studies
              • Overcorrect as some relapse expected
              • Systematic review improve EGD 3-4mm Tawfik 2018
            • Hypermobile lip – Botox Cengiz 2020
              • Reduce muscle activity – levator labil superios LLSAN, zygomaticus minor / major, risorius muscle
              • NOT classified as an alternate treatment for EGD
                • Use = indication for patient outcomes possible for lip reposition
              • Temporary effects – relapse at 6 months
              • Problems
                • Dose related results
                • Excessive upper lip ptorsis
                • Too little – not achieve desired result
                • Smile effected if erroneous
                  • = require expert to use

 

Conclusion

  • Not all patients are the same
  • Age / skeletal / gingival aetiology
  • Explore differential diagnosis
  • Treatment outcome – inter-incisal angle for stability for intrusion
  • Overcorrect intrusion
  • Individualise retention

 

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